A perspective on the health care debate from a progressive, but independent vantage. Offering solid empirical information that sheds light on how the current system actually works, not how it's portrayed.

Gawande and the “great idea” theory

Atul Gawande the physician and New Yorker staff reporter whose June 2009 “Cost Conundrum” article was devoured by pundits and politicians – including the Obama White House – on the way to health care reform, just came out with his newest essay, “The Hot Spotters.”

If you’ve been reading my blog, you know that I haven’t agreed with everything Gawande says – for sure, he hones in on the chaos that masquerades as the American health care “system” and the fragmentation and incentives that drive costs ever higher. He writes well-thought out, compelling stories of those who work in the trenches of medicine, what they do and how they think.

But, Gawande fails to point the way toward progress, because he consistently ignores history and experience outside the U.S. He seems to be ever on the look-out for the “great idea,” the innovation that will transform everything. This is a very American notion, and one that seems to work in the realms of computers and smart phones.

In “The Hot Spotters,” he uncovers another: that if we can identify the relatively few individuals with complex social, economic, and health problems – the 5% of patients who use 50% of the resources – and give them lots of services and support, their lives can be stabilized and their draw on the health care system greatly lessened.

No matter that social workers, community health centers, and social service agencies have known this for a very long time. It’s good that he’s bringing this important observation to the attention of a broader public and to policy makers.

But the field of health care is littered with the corpses of great ideas, some of which researchers and evaluators have even found to be “successful” in their locale or organization of origin. You would have to have a very small hand to hold the handful of these great ideas that actually grew beyond their originators and truly transformed the system around them.

In the real health care world, great ideas stay local or simply die in the face of the overwhelming incentives that drive organizations toward short term profits and risk avoidance, rather than improving health care quality, efficiency, or outcomes.

Gawande finally acknowledged that I may be right. Well, not me, personally … he doesn’t know me from Adam. But in his blog responses to other critics, Gawande allowed that those he calls “The Defeatists” might be right, that “The annals of health care and education are filled with programs that promise to improve lives and save money, but costs still march inexorably upward.”

He claims this is an “eloquent case for despair,” as if the only possible path toward rationality is the “great idea” theory. But it isn’t. In fact, if he was willing to look beyond the American experience, as T.R. Reid did in The Healing of America, he would find plenty of evidence to suggest how we could create a real system of health care and financing that would nurture the innovations he is uncovering rather than smother them.